The AWARE Research Team, led by Dr. Hyeouk "Chris" Hahm at the Boston University School of Social Work. Photo courtesy of BU Today. United States, 2015.

Lily Luo had thought about therapy for a long time. But she never went.

“I didn’t feel ready, especially with the stigmatization within the Asian-American community,” said Luo. “There’s this idea that if you go, you have a problem, which is untrue because you have a problem regardless.”

Luo, a senior studying political science and English at Wellesley College, had contemplated seeking professional help to discuss her childhood. Her mother had grown up during the Cultural Revolution before immigrating to the United States, where she lived in a basement and worked in a Chinatown restaurant for four years. She faced many struggles as an immigrant, including surviving a robbery at her restaurant while eight months pregnant.

“She faced mental health issues for a long time in her life but never had the resources to deal with them, so she unloaded her personal traumas onto me, which I felt shamed for,” said Luo.

Luo had been weary of speaking about abuse with people who did not understand Asian culture. She says she has tremendous respect for all the difficulties her mother overcame as an immigrant in the United States, and she felt worried that outsiders to her family’s way of life would not understand their unique situation.

“Growing up, I had been taught that you can’t talk about things going on inside the family, because if you do, Social Services will take you away, because they don’t understand how Asians discipline our children. I wasn’t encouraged to talk about my feelings,” said Luo.

Luo does not stand alone in her concern. According to data collected from the National Latino and Asian American Study (NLAAS), Asian-Americans are three times less likely to seek mental health services than whites. Another study showed that only 8.6 percent of Asian-Americans sought help for their mental health compared to 18 percent of the general population. Despite their growing presence in the United States, Asian-Americans still suffer from an underutilization of mental health resources. This trend affects young Asian-American women in particular, as they have the second highest suicide rate among all racial/ethnic groups in the United States. The incidence of suicide among young Asian-American women has skyrocketed; according to a 2012 National Center for Health Statistics report, their suicide rate has risen by 96.3 percent from 2000 to 2009.

To combat this rise in suicide and lack of mental health services utilization, Hyeouk “Chris” Hahm, an associate professor at Boston University’s School of Social Work, has dedicated her research to understanding the interrelation of mental health, sexual health, and physical health through her creation of the Asian Women’s Sexual Health Initiative Project (AWSHIP), a five-year study funded by the National Institute of Mental Health, in which over 720 women have participated. The Asian Women’s Action for Resilience and Empowerment (AWARE) project, a component of AWSHIP, targets the mental health of Chinese American, Korean American, and Vietnamese American women by offering culturally-specific group psychotherapy.

“This is the only program in the country targeted toward Asian-American women,” said Hahm. “These women face the pressure of achieving excellence, of getting into Ivy League schools, but in their households and their communities, they also have the additional burden of being perfect daughters.”

Hahm and her team have published over seven journal articles and have given over 30 presentations about their findings from the AWARE initiative. In one study about “fractured identities,” Hahm interviewed 16 Asian-American women who engaged in self-harming and suicidal behaviors. She found that these women often experienced invalidating forms of parenting, which Hahm terms “ABCDG parenting,” an acronym that stands for abusive, burdening, culturally disjointed, disempowering, and gender-prescriptive parenting. Experiencing ABCDG parenting often led these young Asian-American women to use unsafe coping mechanisms instead of seeking professional help.

In a recent study published this past December, Hahm and her team found that out of 701 Asian-American women, 43 percent reported that they suffered from moderate to severe depressive symptoms or a lifetime history of suicidal ideation or suicide attempts. Of these 43 percent, 71 were deemed high-risk, and over 60 percent of these women did not seek any form of mental health care, Over 80 percent did not receive minimally adequate mental health care.

“Asian-American women suffer alone. They suffer quietly, and they die quietly. And even if they die, nobody makes a fuss about it,” said Hahm.

She attributes Asian-American women’s underutilization of mental health services to three factors: stigma from their families, stigma from their communities, and a lack of culturally appropriate treatments.

“Their parents are often dismissive of their mental health problems, labeling them as headaches or as personal weakness, and these women face stigma from the community because they don’t want to be perceived as burdening other people,” Hahm said. “And even when these women do seek treatment, they don’t stick with it, because therapies that were traditionally made for white patients don’t work for them.”

Dr. Joel Wong, an associate professor of Counseling Psychology at Indiana University Bloomington, discusses how family shame can affect young Asian-Americans’ suicide rates. “They experience shame because they think they’ve dishonored their family or made them look really bad, which seems to be an important risk factor for Asian-American college kids experiencing suicidal ideation.”

Stanley Sue, a distinguished professor of Clinical Psychology at Palo Alto University, states that many Asian-Americans may not seek mental health treatment to “save face,” so they can avoid getting noticed. He urges Asian-Americans to overcome their “Asian shyness” and pursue resources so they can thrive in society and take advantage of all the opportunities available to them, including mental health care. He also stresses the systemic factors that may discourage Asian-Americans from seeking treatment.

“The mental health system has not been very responsive to people who are not mainstream and are unfamiliar with psychology, so we don’t have a lot of bilingual or bicultural therapists,” said Sue. “We don’t have a lot of therapists who are sensitive to the kinds of experiences many Asian-Americans have.”

In recent years, more mental health professionals have emphasized the importance of culturally-sensitive therapy. These targeted interventions have been shown to improve treatment outcomes by encompassing a range of activities, such as language match, discussions of clients’ cultural issues, and delivery of therapy in a culturally consistent manner. All of these facets of culturally-competent therapy serve to validate individuals’ backgrounds and experiences.

To address the lack of culturally-sensitive therapy, Hahm developed the AWARE program to focus on the unique challenges and experiences faced by Asian-American women. The intervention integrates culture, family and gender into eight psychotherapy sessions, each with a different topic, ranging from parenting, to racism, to sexual health and substance abuse. These sessions integrate different factors from Asian-American women’s cultural backgrounds to target the double binds they so often face while navigating several different roles in society. Participants also receive encouragement in the form of daily secure text messages called “AWARE stories.”

“We want these women to grasp their inherent worth and beauty, so they can grow in resilience and empowerment,” said Hahm. “We teach them how to grace themselves and accept themselves so they can recognize their values, so they can gain an awareness of their emotions and behaviors. It’s a powerful, life-changing experience.”

Luo heard about the AWARE program at a conference designed to promote excellence and leadership among Asian-American women. She reached out to Hahm and her research team in the fall of her senior year to participate in AWARE. After completing the intervention, Luo said that she found it helpful for many reasons, one of which included the group dynamic of each session.

“Part of the stigmatization of mental health is that you think no one else is going through it, that you’re the only one within the community,” said Luo. “The group setting was really awesome because we got to talk to other women who had all experienced the same things.”

Jane Lee, another woman who participated in AWARE, immigrated to the United States from Korea at a young age. Her family had discouraged her from talking about mental health, saying that only “crazy” people sought therapists. Though she had spent much of her youth thinking about mental health, her parents had pressured her into dealing with her issues on her own.

“The AWARE program helped us open up to each other because of how relatable it was, how even though we were different ages, we realized we had gone through the same things,” said Lee. “It was fascinating because there were actually terms to describe the situations we’ve been through and how our parents treated us.”

Karen Suyemoto, a professor of Clinical Psychology and Asian American Studies at the University of Massachusetts Boston, stresses the importance of not just blaming Asian-American parents. Rather, she encourages people to examine the match between the values of Asian-American children and their parents, as well as the role of discrimination against Asian-Americans.

“Racism has a huge effect on the mental health of Asian-Americans,” said Suyemoto. “Whether it’s the model minority myth, the idea of the forever foreigner, or more blatant racism, the type of racism against Asian-Americans may lead to an increased risk of internalization.”

Suyemoto and her research team at UMass Boston study issues of racialization and social justice within Asian-American communities. Their findings have shown that the ways in which people racialize Asian-Americans often works within a system that undermines other minorities. Suyemoto includes the model minority myth, a stereotype that Asian-Americans have achieved socioeconomic success and full integration into American society despite racial bias, as an example of a microagression used to create divisions to suppress other people of color.

Thomas Chan, a senior at UMass Boston completing his psychology honors project with Suyemoto, experienced his own mental health issues several years ago because of the model minority myth.
“I didn’t like myself because I thought I wasn’t like other Asian-Americans,” said Chan. “It led to me having depression.”

With the support of Suyemoto and other members of their research team, Chan sought therapy at UMass Boston’s counseling center. After completing his current project examining the intersections of racism and mental health symptomology, he aims to pursue a Ph.D. in Clinical Psychology. He states that “I don’t mind if people know about my past struggles, because I want to erase the stigma that people with mental health issues are crazy, because they’re not.”

Luo, who had spent several summers interning for various political campaigns before partaking in the AWARE intervention, states that she had also experienced the effects of racism despite the confidence she always had in herself growing up.

“As an Asian-American women, you still feel the pressure of these stereotypes, which create insecurities inside your head,” said Luo. “Growing up, I was constantly proving myself different from other Asians and other women by speaking up, by asserting myself. I was reacting against the stereotypes.”

Mihoko Maru, a graduate student at Boston University’s School of Social Work and a member of the AWARE research team, states that the session in which participants discuss discrimination often feels revelatory. Having sat in on parts of the AWARE intervention, she notes that the women often feel much better about themselves after finishing the program.

“The stereotype of being quiet and submissive makes Asian-American women more vulnerable to racism, ranging from microagressions to more overt forms of prejudice,” said Maru. “AWARE provides these women with a safe space to disclose things for the first time and get support, so they can learn how to address depression, suicidal ideation, and other stressors.”

After administering the AWARE intervention once more in the spring, Hahm hopes to analyze the program’s efficacy so she can expand it to other Asian-American subgroups, such as Cambodian-American and Laotian-American women. She argues that with the projected rise of the Asian-American population from 18.2 million in 2010 to 40.6 million in 2050, more funds should go toward supporting research on Asian-Americans’ health behaviors, including their mental health and sexual health.

“If we don’t document the mental health, substance use, and sexual health problems of Asian-Americans, NIH won’t support us,” said Hahm. “The AWARE program gives us and these women a catalyst, an opportunity, to think about their childhood, their family dynamics, and how to develop coping skills that will help them in the future.”

Luo still stays in contact with the other women she experienced AWARE with, having gotten dinner with them later on that same fall semester. After going through AWARE, she realized her passion for mental health and integrating it into her work in community organizing. In the future she wants to create alternate parallel institutions to empower more Asian-Americans to feel assured of themselves and their mental health. Her mother has also become more receptive toward discussing issues like mental health, even if the topics still feel a little uncomfortable.

“AWARE made me more confident to speak about these issues and to acknowledge these things, because we all went through them,” said Luo. “There’s a way for us to deal with these things in healthy, self-affirming ways, in ways that give us hope."